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IM5.1-17 | Liver Disease — Assignment

CLINICAL SCENARIO

You are the intern on the gastroenterology ward. Mr Rajan Sharma, a 52-year-old man from a semi-urban area in Telangana, is admitted with progressive abdominal distension for 3 months and an episode of haematemesis 5 days ago. He has been drinking approximately 80 g of alcohol per day for 20 years. He stopped alcohol after the bleed. On examination: scleral icterus, palmar erythema, Dupuytren contracture, parotid enlargement, spider naevi (×6 on chest), gynaecomastia, flapping tremor (mild asterixis). Abdomen: tense ascites, splenomegaly 2 cm below left costal margin, no palpable liver edge. Investigations sent: CBC, LFTs, serum albumin, PT/INR, serum sodium, creatinine, HBsAg, anti-HCV, ultrasound abdomen (report pending). Your task is to write a structured clinical case analysis as outlined below.

Instructions

Write a structured clinical case analysis for Mr Rajan Sharma using the five sections below. Use precise clinical language with named drugs and doses. Apply the scoring systems and thresholds taught in the module — do not use class names in place of drug names. Do not copy SDL text verbatim; integrate your reasoning. Word limit: 1,100–1,500 words.

Length: 1,100–1,500 words across all sections

What to Submit

Section 1: History Synthesis and Examination Findings

Guidance: Organise the history into the six domains of a structured liver disease history: current presentation (acute vs chronic, hepatocellular vs cholestatic features), alcohol history (quantify in grams/day using standard drink conversion; 1 standard drink = 10 g ethanol), medication and herbal/Ayurvedic drug use, sexual history and vaccination status, family history, and review of systems. For examination: list the stigmata of chronic liver disease you find, group them as features of portal hypertension vs hepatic insufficiency, and state the pathophysiological mechanism for each sign. Approximately 300 words.

Section 2: Differential Diagnosis

Guidance: List at least three diagnoses in order of probability. For each, state the clinical features from this case that support or argue against it. Identify the single most discriminating feature that makes the leading diagnosis most likely. Include alcoholic cirrhosis, viral hepatitis-related cirrhosis, and at least one non-cirrhotic cause of portal hypertension in your list. Approximately 200 words.

Section 3: Investigation Plan and Interpretation

Guidance: Outline first-line investigations (with rationale for each) and the second-line investigations you would request if the first-line results returned showing a hepatocellular pattern. State the LFT pattern you expect in alcoholic cirrhosis (include the AST:ALT ratio and its significance). Apply the SAAG formula to a hypothetical paracentesis result (serum albumin 2.4 g/dL, ascitic albumin 0.6 g/dL) and interpret it. Select and justify the hepatitis serology panel for this patient. Approximately 250 words.

Section 4: Management Plan for Cirrhosis Complications

Guidance: Mr Sharma has three active complications: (1) probable variceal haemorrhage (the presenting bleed 5 days ago), (2) tense ascites, and (3) mild hepatic encephalopathy. For each: write a specific management plan with named drugs, doses, and monitoring targets. State the Child-Pugh or MELD parameters you would apply to stage his disease. Include at least one threshold-driven management decision with the threshold explicitly stated (e.g., the PMN count threshold for SBP diagnosis and treatment, or the terlipressin timing rule for variceal haemorrhage). Approximately 350 words.

Section 5: Prognosis and Transplant Assessment

Guidance: Using the Child-Pugh score, classify Mr Sharma and state his approximate 1-year survival. Then state the criteria you would apply to determine eligibility for liver transplant assessment: MELD threshold, abstinence requirement, and the two most important contraindications you would screen for. Draft a two-sentence explanation you would give the patient explaining why transplant evaluation is being considered and what the abstinence requirement means for his candidacy. Approximately 150 words.

Grading Rubric — Liver Disease Case Analysis Rubric

Criterion	Points	Full-marks descriptor
History and Examination Synthesis (Section 1): Elicits all six relevant history domains (current presentation, alcohol history quantified in grams/day, medication/herbal use, sexual and vaccination history, family history) and identifies key physical examination signs relevant to aetiology and severity staging.	20 pts	All six history domains addressed with appropriate detail; alcohol quantified in grams/day; physical signs accurately linked to pathophysiological mechanisms; examination findings correctly assigned to aetiology vs severity.
Differential Diagnosis and Prioritisation (Section 2): Generates a prioritised differential diagnosis (at least three conditions), assigns probability weights based on clinical features, and identifies the single most discriminating clinical feature for the leading diagnosis.	15 pts	Three or more diagnoses listed with explicit probability weighting; leading diagnosis supported by the most discriminating clinical or biochemical feature; alternative diagnoses have stated clinical reasoning.
Diagnostic Investigation Plan (Section 3): Selects appropriate investigations in a logical first-line and second-line sequence; correctly interprets the LFT pattern (hepatocellular vs cholestatic); applies the SAAG formula correctly; selects hepatitis serology appropriate to the clinical scenario.	20 pts	Investigations sequenced logically (first-line panel then targeted); LFT pattern correctly named and mechanistically explained; SAAG formula stated as serum albumin minus ascitic albumin with correct threshold (≥1.1 = portal hypertension); relevant serology correctly selected and interpreted.
Management Plan for Cirrhosis Complications (Section 4): Constructs a specific, evidence-based management plan addressing at least two cirrhosis complications from the case; correctly names and applies the Child-Pugh score OR MELD score with correct parameters; applies threshold-based management decisions.	25 pts	Two or more complications managed with named drugs, correct doses, and treatment thresholds; Child-Pugh or MELD parameters stated correctly with class/score; at least one threshold-driven decision (e.g., SBP: PMN ≥250 → start cefotaxime immediately; variceal bleed: terlipressin + antibiotics before endoscopy) stated explicitly.
Prognosis and Transplant Referral Threshold (Section 5): Correctly applies prognostic scoring to communicate disease severity to the patient and family; identifies at least one indication for hepatic transplant referral relevant to the case.	15 pts	Prognosis communicated using Child-Pugh class or MELD score with correct predicted 1-year survival range; transplant indication correctly identified (MELD ≥15, or specific complication threshold); eligibility criteria including abstinence requirement stated for alcoholic aetiology.
Communication and Clinical Reasoning Quality (across all sections): Logical, precise clinical language; uses named drugs (not class names only); avoids copying SDL text verbatim; demonstrates integration of findings rather than listing.	5 pts	Precise clinical language throughout; named drugs with doses; findings integrated into coherent reasoning; no verbatim SDL reproduction.

PEER REVIEW

Review your peer's case analysis using the rubric. For each section, assign a score and write one specific comment. For Section 3, verify that the SAAG is calculated correctly (serum albumin minus ascitic albumin, not protein) and the threshold of ≥1.1 g/dL is correctly cited. For Section 4, check that all three complications have named drugs with doses and that at least one threshold decision is explicitly stated with the numerical threshold. For Section 5, confirm that the Child-Pugh class is correctly matched to the survival statistic cited. Complete your review within 72 hours.